Making Hard Decisions About Breast Cancer Surgery and Reconstruction and How We Can Help

A breast cancer diagnosis can feel overwhelming, leaving you with complex decisions that impact not only your treatment but also your body, emotional well-being, and long-term quality of life. Among the most critical decisions are those surrounding surgery and potential reconstruction. These choices are deeply personal, which means what feels right for one person may not suit another.

Making the best decision requires more than medical information. It involves understanding your options, aligning your treatment with your values and lifestyle, and having a supportive team to guide you.

Understanding Your Surgical Options

The first step in your breast cancer journey is deciding which surgical approach aligns best with your diagnosis and personal goals. Modern techniques make both breast-conserving surgery and more extensive mastectomies safer and more effective, while also optimizing long-term outcomes.

Lumpectomy (Breast-Conserving Surgery)

This procedure involves removing the cancerous tumor along with a small margin of surrounding healthy tissue. It is typically followed by radiation therapy to eliminate any remaining cancer cells in the breast. 

Modern lumpectomies are often combined with oncoplastic techniques, where the surgeon sculpts the remaining breast tissue to maintain a natural shape and prevent divots or deformities, sometimes even performing a lift or reduction on the other breast for symmetry. This approach is ideal for those with smaller, single-site tumors who wish to preserve their natural breast.

Mastectomy (Removal of the Breast)

This involves the removal of the entire breast tissue. However, a mastectomy today is not a one-size-fits-all procedure. Advanced techniques focus on preserving as much of the natural breast envelope as possible to create a better foundation for reconstruction. 

The choice between a lumpectomy and a mastectomy depends on factors like tumor size and location, breast size, genetic mutations (like BRCA1/2), and your personal preference regarding radiation therapy and long-term surveillance. This includes:

• Skin-Sparing Mastectomy: The surgeon removes the breast tissue, nipple, and areola but leaves the majority of the breast skin intact.
• Nipple-Sparing Mastectomy: This is a highly advanced option for eligible candidates where the breast tissue is removed, but the skin, nipple, and areola are all preserved. This technique can yield the most natural-looking reconstructive results.
• Modified Radical Mastectomy: This procedure involves removing the breast tissue, nipple, areola, and most of the axillary (underarm) lymph nodes. It is generally reserved for cases where cancer has spread to the lymph nodes.

Exploring Breast Reconstruction Options

If your surgery results in significant volume loss, reconstruction becomes an important part of your journey. Breast reconstruction is not purely cosmetic, as it plays a central role in restoring your sense of self, physical balance, and emotional well-being. One of the first choices is timing

Immediate Reconstruction

The reconstruction process begins during the same surgery as the mastectomy. This offers the psychological benefit of waking up with a breast mound already in place and often yields better cosmetic results as the natural skin envelope is preserved.

Delayed Reconstruction

Reconstruction is performed in a separate surgery weeks, months, or even years after the mastectomy. This may be recommended if you require post-mastectomy radiation, which can damage reconstructed tissue, or if you simply need more time to make a decision.

Types of Reconstruction

The methods for rebuilding a breast are sophisticated and can be tailored to your body type, lifestyle, and aesthetic goals. You can choose from is: 

Implant-Based Reconstruction

• The Two-Stage Approach: The standard technique involves placing a tissue expander, either under the pectoral muscle (subpectoral) or, in a newer approach, on top of it (pre-pectoral). This expander is gradually filled with saline over several weeks to create a pocket for the permanent implant, which is placed in a second, smaller surgery.
• Direct-to-Implant (DTI) Reconstruction: For select patients with smaller breasts and good skin quality, the permanent implant can be placed during the initial mastectomy surgery, eliminating the need for a second procedure and the expansion process.
• The Pre-Pectoral Advantage: Placing the expander or implant on top of the chest muscle is a significant advancement. This technique avoids cutting the pectoral muscle, resulting in less postoperative pain, a quicker recovery, and the elimination of "animation deformity," where the implant moves unnaturally with chest muscle contraction.
• Advanced Materials: Modern implants are available in various shapes, sizes, and textures. Cohesive silicone gel ("gummy bear") implants hold their shape better and reduce the risk of rippling, providing a more stable and natural feel.

Autologous (Flap) Reconstruction

Autologous, or "flap," reconstruction uses a patient's own skin, fat, and blood vessels to create a new breast. This method produces a result that feels soft, warm, and natural, and it evolves with the patient's body over time.

• DIEP Flap: The Deep Inferior Epigastric Perforator (DIEP) flap is the most advanced form of abdominal-based reconstruction. Surgeons meticulously transfer skin and fat from the lower abdomen to the chest without sacrificing any of the underlying abdominal muscle. This preserves core strength and significantly reduces recovery time compared to older flap techniques. The added benefit is a flatter abdomen, similar to a "tummy tuck."
• Alternative Donor Sites: For women who lack sufficient abdominal tissue, other flap options are available. The SGAP/L-GAP flap uses tissue from the buttocks, while the TUG/VUG flap utilizes tissue from the inner thigh. These sophisticated microsurgical procedures provide living, natural-feeling breasts for a wider range of body types.
• Restoring Sensation: During a flap procedure, the surgeon can meticulously connect a sensory nerve from the transferred tissue to a nerve in the chest. Over time, this can allow for the return of sensation to the reconstructed breast, a profound step in restoring a sense of wholeness.

A Modern Framework for Making Your Decision

A successful surgical and reconstructive plan begins with assembling the right team. When your team communicates effectively, you benefit from a unified plan that balances oncologic safety, reconstructive outcomes, and long-term health. This coordination also allows your surgeons to optimize incisions and preserve skin for reconstruction. Breast cancer care is most effective when coordinated across specialists:

Define Your Personal Priorities

Think about what matters most to you. Do you prefer a faster recovery, or are you open to a more involved surgery for a specific long-term outcome? Would you rather use implants or your own tissue? Clarifying your personal goals helps guide every decision that follows.

Seek Multiple Expert Opinions

Consult at least two plastic surgeons. Each offers different experiences and insights, helping you compare surgical options and make an informed, confident choice.

Inquire About Clinical Trials

Ask your team if you qualify for any clinical trials. These may offer access to new reconstructive techniques, implant materials, or therapies that enhance results and recovery.

Visualize the Possibilities

Request before-and-after photos of patients with a similar body type. Seeing real results helps set clear expectations and identify which approach best matches your goals.

Need an expert, multidisciplinary team? LA Cancer Network is dedicated to providing personalized solutions for you. We are here to help you build a treatment plan that aligns with your medical needs and personal goals. Schedule your consultation and begin your journey with a supportive and knowledgeable team by your side with us today!